Refer A Patient

Use this easy fill-in form to request assessment of a patient for possible admission to Hampton Roads Specialty Hospital. You also have the option to call in a referral by dialing (757) 928-8440 or faxing information to (757) 928-8225.

Note: Red Text indicates a required field.

Please assess the following patient to see if he/she is appropriate for admission to Hampton Roads Specialty Hospital.

Information on Patient

Current Patient Location

Patient Insurance(s)

Referred By